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LWBK942-FM.qxd 6/25/11 8:45 AM Page x Student Student Laboratory Laboratory Manual Manual for for Bates’ Nursing Guide to Physical Examination and History Taking LWBK970-FM_i-vi.indd i 8/12/11 10:03 PM Acquisitions Editor: Elizabeth Nieginski Product Manager: Katherine Burland Editorial Assistant: Jacalyn Clay Design Coordinator: Holly MacLaughlin Manufacturing Coordinator: Karin Duffield Prepress Vendor: Aptara, Inc. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Lippincott Williams & Wilkins at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at permissions@lww.com, or via our website at lww.com (products and services). 9 8 7 6 5 4 3 2 1 Printed in China ISBN: 978-0-7817-8063-6 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in his or her clinical practice. LWW.com LWBK970-FM_i-vi.indd ii 8/12/11 10:03 PM Preface This Student Laboratory Manual was written by Jo Anne Kirk, RN, MSN, to accompany Bates’ Nursing Guide to Physical Examination and History Taking by Beth Hogan-Quigley, Mary Louise Palm, and Lynn S. Bickley. Each chapter has a corresponding textbook chapter and contains activities to help you retain and apply the knowledge you have gained from the associated textbook. The following information outlines the purpose of each section of the Laboratory Manual: ■ Learning Objectives. Each chapter begins with a review of the stated Learning Objectives from the corresponding textbook chapter. ■ Study Guide. The Study Guide portion of each chapter includes combinations of Fill in the Blank, Labeling, Matching, Sequencing, Short Answer, and Multiple Choice questions. All of these exercises help students to reinforce knowledge, synthesize concepts, prepare for tests, and ensure their understanding of Physical Examination and History Taking. An answer key to each chapter is provided at the end of the manual. ■ Case Studies. These scenarios focus on critical thinking. They ask students to consider how responses to patients would change with different assessment data, patient background, medical diagnoses, and other key variables. ■ Documentation. Where applicable, the chapters include the Form for Use in Practice, which serves as a quick checklist by which students can ensure that they are covering all key areas of the health history and physical assessment. This serves to help guide students through their clinical experiences. The authors and publisher sincerely hope that this product achieves the goals of assisting with learning and optimizing comprehension and application to facilitate quality health assessments and competent nursing care. iii LWBK970-FM_i-vi.indd iii 8/12/11 10:03 PM LWBK970-FM_i-vi.indd iv 8/12/11 10:03 PM Contents UNIT CHAPTER I 10 The Head and Neck 40 FOUNDATIONS CHAPTER CHAPTER 1 The Eyes 11 45 Introduction to Health Assessment 1 CHAPTER CHAPTER 2 12 Ears, Nose, Mouth, and Throat 50 Critical Thinking in Health Assessment 5 CHAPTER CHAPTER 3 13 The Respiratory System 57 Interviewing and Communication 9 CHAPTER CHAPTER 4 The Health History The Cardiovascular System 63 13 CHAPTER CHAPTER 5 6 Physical Examination CHAPTER CHAPTER 7 8 CHAPTER 27 CHAPTER 18 19 Mental Status BODY SYSTEMS CHAPTER 9 The Integumentary System 79 The Musculoskeletal System 85 II CHAPTER 17 The Breasts and Axillae CHAPTER Nutrition 31 UNIT 16 The Gastrointestinal and Renal Systems 73 23 Beginning the Physical Examination: General Survey, Vital Signs, and Pain CHAPTER 15 The Peripheral Vascular System and Lymphatic System 68 Cultural and Spiritual Assessment 19 CHAPTER 14 91 20 The Nervous System 96 35 v LWBK970-FM_i-vi.indd v 8/12/11 10:03 PM vi CONTENTS CHAPTER 21 Reproductive Systems CHAPTER 101 22 Putting It All Together UNIT CHAPTER 24 Assessing Older Adults Answer Key 120 125 107 III SPECIAL LIFESPAN CHAPTER 23 Assessing Children: Infancy through Adolescence 114 LWBK970-FM_i-vi.indd vi 8/12/11 10:03 PM CHAPTER Introduction to Health Assessment SECTION I: LEARNING OBJECTIVES Learning Objectives The student will: 1. Define health and health assessment. 2. Identify the health indicators and purpose of Healthy People 2020. 3. Explain the components of the health assessment. 4. Clarify the nurse’s role in assessment. SECTION II: STUDY GUIDE Activity A FILL IN THE BLANK 1. Complete the following statements: A. The nursing health assessment focus is to _______________________________________ _______________________________________ _______________________________________ _______________________________________. B. The nursing health assessment is used _______________________________________ _______________________________________ _______________________________________ _______________________________________. 1 C. The physical examination performed by the nurse is done to ____________________ _______________________________________ _______________________________________ _______________________________________ _____________. D. The nurse performs a systematic data collection called a _______________________________________ _______________________________________ _______________________________________ ____________. E. Having taken the lead in health promotion, nurses are able to assist their patients to _______________________________________ _______________________________________ _______________________________________ _______________________________________. 2. List the facets of health. A. B. C. D. E. F. 1 LWBK970-C01_p01-04.indd 1 8/5/11 9:46 PM 2 UNIT 1 FOUNDATIONS Activity B MATCHING 3. Match the level of prevention with its definition. Level of Prevention Definition Primary A. Decreasing the effects of a disease or disability by preventing complications and additional loss that happens when a defect is permanent Secondary B. Improving the overall wellness and protection from disease or disability Tertiary C. Early detection and treatment of a disease when it is curable or has few complications or disabilities 4. Match the examples of prevention with their corresponding level of prevention. (Level of preven- tion may be used more than once.) Example Level of Prevention Communicable disease control A. Primary Health education B. Secondary Periodic selective examinations C. Tertiary Sheltered communities Provision of adequate housing Provision of hospital and community facilities Reducing risk factors Early treatment of diseases Self-examination Rehabilitation programs 7. The authors state that the health assessment Activity C SHORT ANSWER 5. The ability to maintain health includes inte- is similar to a puzzle. Explain this. grating a variety of components. Discuss these components. 8. The nursing health assessment enables nurses 6. List the leading health indicators for 2020 and discuss where they came from. to detect areas that need adjusting. Explain what nurses are able to assist their patients to do and what this enables the patient to do. Copyright © 2012. Wolters Kluwer Health | Lippincott Williams & Wilkins. Student Laboratory Manual for Bates’ Nursing Guide to Physical Examination and History Taking. LWBK970-C01_p01-04.indd 2 8/5/11 9:46 PM